Everyone Counts: Planning for Patients 2013/14

1

MORE PATIENT

BETTER

HIGHER

MORENHS services

7 DAYS A WEEK TRANSPARENCY

PARTICIPATION

CUSTOMER SERVICE

STANDARDS

SAFER CARE

SUNDAY ?every day

health service

#1

MORE

BETTER

INFORMED

IMPROVED

CHOICE

DATA

COMMISSIONING

OUTCOMES

AND +

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The NHS and all of us who work in it can be justly proud of the achievements we have made over recent years.

Foreword- a message to all NHS staff

We have made it possible for the NHS Constitution to set out rights and pledges that were unthinkable not so long ago. We wait less, are diagnosed and referred quicker and our hospitals have fewer infections. Those things have not happened by accident or structural tinkering but by the hard work of NHS staff. I am truly grateful for all you have done. Whether you are a commissioner, provider or partner, thank you.

But we can’t rest on our laurels. We must remain committed to improvement while understanding the risks and challenges we now face. The economic situation means that resources are going to be limited for some time. For us that brings about more challenges with an ageing population and greater demand on our services. If we don’t get it right then our patients will suffer. That means finding better ways of delivering services – we must get the best possible value in patient outcomes from every pound spent in the NHS. And the appalling standards of care that came to light at Winterbourne View and the Mid Staffordshire NHS Foundation Trust are stark examples of what can happen when we are not all focused on why we work for and with the health service – better and improved standards of care for all.

In our vision of a modern, patient-centred NHS, improvements will be driven by the new clinically-led, local commissioning system. Our job as the NHS Commissioning Board is to support clinical commissioning groups to develop and deliver these improvements.

We must ensure patients’ and their families’ voices are heard and used to help us develop the insight to improve outcomes and guarantee no community is left behind or disadvantaged. We want to make the NHS the best customer service in the world and throughout the NHS, we must all strive to design and deliver care based on the needs and choices of each individual patient.

Sir David Nicholson KCB, CBEChief Executive

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Focussing on outcomes to plan NHS services represents a significant opportunity to build on our achievements to date. Across the NHS, we need to work to prevent people from dying prematurely, enhance the quality of life for people with long-term conditions, help people to recover from ill health or injury, ensure that people have a positive experience of care and ensure that people are treated and cared for in a safe environment, protected from avoidable harm. At the same time, we must not fall into the trap of thinking that because we have improved access that the job is done – the rights and pledges in the NHS Constitution must be delivered for everyone who uses the services we commission.

The new system gives pride of place to clinical leaders. From top to bottom and across the country it assumes liberty – freedom for you to take clinical ownership and leadership, and for local communities and commissioners to decide for themselves how best to deliver care.

Although we will retain oversight in order to assure responsibilities are being met, we will not sit above you issuing operating instructions - we will stand with you, helping you to carefully allocate valuable public resources to secure the best possible outcomes for patients.

The NHS Commissioning Board wants to provide the right support and tools to help you design and transform services for patients. The approach set out in this planning framework is aimed at securing three important objectives:• balancingchangeandcontinuity: 2013/14 sees widescale organisational change at a time of

increasing financial pressures and the best confidence we can provide patients and the public is that local health services are driving change, not reacting to it;

• making assumedliberty a reality through creating the time and space for clinical commissioning groups to drive local health priorities within a framework driven by Health and Wellbeing Boards; and

• balancingannualrequirementswiththelongerterm: the best indicator we have of future quality improvement is current delivery and we need to assure ourselves that the health service is sufficiently robust to deal with the challenges of increasing demand when limited resource growth is likely to be a feature for several years ahead.

We have been successful in our journey so far and I am confident we shall be successful under the new structures.

SirDavidNicholsonKCB,CBE

ChiefExecutive

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EXECUTIVE SUMMARY

Empowered local clinicians delivering better outcomes; increased information for patients to make choices; and greater accountability to the communities the NHS serves.

These are the principles behind our new approach

to planning clinical led-commissioning from April

2013.

As the body charged with overseeing

and supporting this new system the NHS

Commissioning Board exists to enable excellence

in healthcare. The NHS Outcomes Framework

and NHS Constitution set out the goals and

responsibilities – but the approaches for delivery

will vary and local commissioners will have freedom

to develop those that work in their community.

Healthcare success in the future will be judged on

the quality of outcomes.

At a time of significant financial challenge, where

we need to ensure all organisations are robust to

address the challenges facing them, this document

lays out five offers to help commissioners deliver

for the public: support for routine NHS care seven

days a week; greater transparency on outcomes;

mechanisms to enhance patient feedback; better

data collection to drive evidence-based medicine;

and for high professional standards. Alongside

these are details of the package of guidelines and

incentives that demonstrate a new relationship

between those directly developing services and

those working at a national level. Among the

measures covered in this document are:

Listening to patients

• The rights of patients set out in the NHS

Constitution are vital. They must be delivered.

• Customer convenience - the NHS will move to

providing seven days a week access to routine

healthcare services.

• Real-time experience feedback from patients

and carers by 2015.

• A Friends and Family Test to identify whether

patients would recommend their hospital to

those with whom they are closest.

Focusing on outcomeS

• Publication of consultant-level outcome data

covering mortality and quality for ten surgical

and medical specialties.

• NHS Outcomes Framework will now inform NHS

planning. Commissioners will be expected to

prioritise and make improvements against all

indicators.

Rewarding excellence

• Continued financial and related levers and

enablers for clinical commissioning groups

to use when commissioning for better patient

outcomes.

• A Quality Premium for clinical commissioning

groups who secure quality improvement against

certain measures from the NHS Outcomes

Framework

• Support for clinical commissioning groups

to define their local QIPP challenge and set

milestones.

• CQUIN payments only available to providers

who meet the minimum requirements concerning

the high-impact innovations, as set out in

Innovation, Health and Wealth.

• During 2013/14, a fundamental review of the

incentives, rewards and sanctions available to

commissioners to drive improvements in care

quality.

Improving knowledge and data

• NHS Standard Contract to require all NHS

providers to submit data sets that comply with

published information standards.

• Care.data - a modern knowledge service for the

NHS will provide commissioners with timely and

accurate data.

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5

Seizing the opportunity: a new approach to NHS planning

Towards “assumed liberty” for local

commissioning

1.1 The challenge facing the NHS is to become

truly patient-centred, where patients

participate in designing services and are

able to exercise choice as customers,

whilst seeking always to ensure that no

community or part of a community gets

left behind. In everything we do, mental

health should have equality of esteem

with physical health. This section sets

out the structure that will create patient-

centred services. It provides detail on

the support that the NHS Commissioning

Board will provide clinical commissioning

groups. Commissioners will be offered

improved patient satisfaction measures;

better comparable clinical data; greater

transparency; commitment to improve

access to services; and enhanced

professional standards.

1.2 On 13 November 2012 the Government

published its mandate1 to the NHS

Commissioning Board and this set the

strategic framework within which we will

discharge our responsibilities. We are

committed to deliver all our objectives and

this planning guidance is part of how we

will work with local commissioners to see

that they are met. In doing so, we are

mindful that we are facing unprecedented

challenges of an ageing population,

greater demand and limited resource

growth. These challenges mean that all

NHS organisations need to play their part

in improving services for patients to secure

better value from every pound spent on the

NHS.

1.3 Together, NHS commissioners exist

to drive improvements in services to

patients. The planning process enables

us to define improvement and ensure

commissioners have the means to make

changes that maximise patient benefit.

This document sets out the shared interests

of commissioners and how we can work

together for the people we serve.

1.4 2013/14 is the first year of a reformed

health service where greater local control

of decision-making leads to better patient

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outcomes and service improvements.

Our NHS will be driven by local people

through greater public participation and

transparent access to data. Clinical

commissioning groups and local

communities are empowered to prioritise

on the basis of local needs and patient

and public preferences – liberty is

assumed rather than granted.

1.5 The NHS Commissioning Board will be

one player in securing better services

for patients, providing leadership of the

NHS commissioning system and support

for clinical commissioning groups to help

them realise their own ambitions. We will

support real action to address variation in

the quality of care and health inequalities.

1.6 We are taking an approach to secure

better outcomes as defined by the

five domains of the NHS Outcomes

Framework2 and upholding the rights

and pledges within the NHS Constitution3

within available resources. In doing so,

we will not be asking anything of local

commissioners that is not being asked of

the NHS Commissioning Board or set out

in statute.

1.7 We will use the information we receive

from clinical commissioning groups and

our own direct commissioning to assure

ourselves that:

• each clinical commissioning group

and the NHS Commissioning

Board itself are maximising quality

improvements within their resource

allocations;

• commissioning by clinical

commissioning groups and the

NHS Commissioning Board is

complementary in driving overall

improvement;

• we have the information we need

for public accountability on the

performance of the NHS; and

• NHS organisations are taking the

decisions they need to ensure longer

term sustainability and success.

1.8 We will support commissioners by

ensuring that we all have comparable

data. The NHS Standard Contract will

include the requirement that all NHS

funded providers submit data sets that

comply with published information

standards. We will work with Healthwatch

England to identify national issues of

patient interest and with local Healthwatch

on areas of direct commissioning. We will

expect clinical commissioning groups to

do the same when developing their own

plans.

Patient-centred, customer-focused

1.9 This guidance addresses two key

challenges:

• guaranteeing no community is left

behind or disadvantaged – the

commissioning system needs to

be focused on reducing health

inequalities and advancing equality

in its drive to improve outcomes for

patients; and

• treating patients respectfully as

customers and putting their interests

first – transforming the service offer of

the NHS so that they can take control

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and make more informed choices, if

they want to.

1.10 To meet these challenges, a patient-

centred approach and the reformed

structures provide three inter-related

lenses through which planning can be

viewed:

• local area based planning;

• clinical commissioning group

organisational planning; and

• direct commissioning by the NHS

Commissioning Board.

More detail on each of these is provided

later in this section.

1.11 We are committed to making time and

space for local commissioners to identify

and focus where they have identified a

real health and wellbeing need for their

area.

1.12 Rather than set targets, we have been

working with clinical commissioning

groups to identify what support the NHS

Commissioning Board can offer to drive

improvements in services to patients. An

NHS Commissioning Assembly has been

established to bring together leaders

across NHS commissioning and organised

around a single goal of securing the

delivery of better outcomes for patients.

1.13 As a first step, the NHS Commissioning

Board will provide five offers to NHS

commissioners to give them the insights

and evidence they need to produce better

local health outcomes.

Offer 1: NHS services, seven days a week

1.14 The NHS will move towards routine

services being available seven days a

week. This is essential to offer a much

more patient-focused service and also

offers the opportunity to improve clinical

outcomes and reduce costs.

1.15 The limited availability of some hospital

services at certain times can have a

detrimental impact on all five domains

of the NHS Outcomes Framework. Our

National Medical Director will establish

a forum that includes national and local

commissioners, providers and regulators to

identify how there might be better access

to routine services seven days a week and

report in the autumn of 2013. As a first

stage, the review will focus on improving

diagnostics4 and urgent and emergency

care. It will include the consequences

of the non-availability of clinical services

across the seven day week and provide

proposals for improvements to any

shortcomings. Emergency care should

not be used when patients would benefit

from care in other settings. Through our

own direct commissioning and working

with clinical commissioning groups, we

will ensure that primary and community

based services also deliver a high quality,

responsive service both in and out of hours.

Offer 2: More transparency, more choice

1.16 It is critical that patients and commissioners

understand the quality of services

being delivered within hospitals and

other healthcare settings. To enable

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this, with oversight from our National

Medical Director, the Healthcare Quality

Improvement Partnership (HQIP)5 will

develop methodologies for casemix

comparison and, in conjunction with

NHS Choices, publish activity, clinical

quality measures and survival rates from

national clinical audits for every consultant

practising in the following specialties:

• adult cardiac surgery;

• interventional cardiology;

• vascular surgery;

• upper gastro-intestinal surgery;

• colorectal surgery;

• orthopaedic surgery;

• bariatric surgery;

• urological surgery;

• head and neck surgery; and

• thyroid and endocrine surgery.

1.17 These data will be published by summer

2013. Commissioners should ensure

that each of their providers publishes

its own information on these specialties

on its website in a format defined by

HQIP. Publication will be part of the NHS

Standard Contract from 2014/15 to allow

for comparisons across hospitals.

1.18 This work is a ground-breaking step

towards ensuring the rights and pledges

set out in the NHS Constitution,

including patients’ right to choose the

most appropriate setting for care, are

delivered. This means choice both at

the point of GP referral and along the

care pathway. Choice and competition

incentives are important insofar as they

contribute to achieving better outcomes

for patients and local communities. The

NHS Commissioning Board is working in

partnership with Monitor to make available

the best evidence of how, where and what

circumstances choice and competition has

the potential to make the biggest positive

difference. By March 2013 we will have

begun to publish practical, evidence-based

guidance and tools to support patients,

commissioners and providers.

Offer 3: Listening to patients and increasing

their participation

1.19 We need to know more about what

our patients think of the services we

commission and act on that information

in designing and delivering services. We

recognise a particular responsibility to

ensure that the voice and views of currently

disadvantaged groups are sought out and

listened to.

1.20 We will expect commissioners to work with

providers to put in place mechanisms for

systematically capturing real-time patient

and carer feedback and comment, as well

as developing plans to gather public insight

on local health services. Our aim is to

ensure that all NHS funded patients will

have the opportunity to leave feedback in

real time on any service by 2015. This will

start with a Friends and Family Test which

will be introduced for all acute hospital

inpatients and Accident and Emergency

patients from April 2013 and for women

who have used maternity services from

October 2013. This will identify whether

patients would recommend the hospital

to those with whom they are closest and

be an important part of the assurance

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of clinical commissioning groups by the

NHS Commissioning Board. Clinical

commissioning groups will need to

demonstrate what action they have taken

as a consequence of feedback from the

Friends and Family Test and work with

providers on further roll-out from 2014/15.

1.21 In 2013/14 commissioners are expected

to work with local Health and Wellbeing

Boards to assess local population needs

and with local Healthwatch to ensure that

plans for patient and public involvement

match local people’s expectations for how

they wish to be engaged at both individual

and collective level. Commissioners are

encouraged to develop local metrics for

evaluating the social and economic return

on investment and other impacts of their

patient and public involvement activities.

1.22 We want to put patients in control and

to offer them a world class customer

service. For this reason, we will prioritise

innovation in developing services around

the needs of patients and the public. We

will guarantee every patient the opportunity

of online access to their own primary care

medical record by the spring of 2015 and

we will consult, by June 2013, on plans for

provision of patient access to interoperable

records across the pathway of care.

1.23 In line with the recommendations of

Innovation Health and Wealth: Accelerating

adoption and diffusion in the NHS6 we

will expect commissioners to promote

the benefits of technology in improving

outcomes with a particular emphasis on

much more rapid take up of telehealth and

telecare in line with patient need. We will

support commissioners to provide patients

with access to digital tools to help them

manage health and care as they choose

and shall also support a move to paperless

referrals in the NHS by March 2015 so

that patients and carers can easily book

appointments in primary and secondary

care.

Offer 4: Better data, informed commissioning,

driving improved outcomes

1.24 High quality relevant data is a key tool for

commissioning – it underpins assumed

liberty for clinical commissioning groups.

We will work to ensure information systems

are improved and integrated where

necessary. We will build a modern data

service, care.data, in health and social

care. This will provide timely, accurate

data derived from information collected as

part of the care process and linked along

care pathways. This will require universal

adoption of the NHS number as the primary

identifier by all providers in 2013/14.

1.25 To ensure that clinical commissioning

groups have the information they need to

make informed decisions about secondary

care and enable commissioning for

integrated care, we will collect a core set of

clinical data from GP practices for 2013/14.

This will support clinical commissioning

groups’ analysis of outcomes along

patient pathways, while maintaining patient

confidentiality. This dataset is published

alongside this planning framework.

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1.26 Throughout 2013/14 commissioners must

use sanctions within the NHS Standard

Contract if they are not satisfied over the

completeness and quality of a provider’s

data on the Secondary Uses Service

(SUS).

1.27 We will work with clinical commissioning

groups and providers to develop

comprehensive clinical data for secondary

care which we will consult on before

development of planning guidance for

2014/15. We will expect secondary care

providers to be able to account for the

outcomes of all patients they treat and to

adopt modern, safe standards of electronic

record keeping by 2014/15. In 2013/14

we will expect secondary care providers to

comply with data collections that have been

approved by the Information Standards

Board, including the Systemic Anti-Cancer

Therapy dataset and Cancer Outcomes and

Services dataset which will help us improve

cancer outcomes for patients.

1.28 To support clinical commissioning

groups develop their capacity to improve

data quality, the NHS Commissioning

Board’s National Director for Patients and

Information will produce advice by 31

March 2013 on what a high quality data

set should look like and ask each clinical

commissioning group to identify its own

strategy in the light of our advice by 30

September 2013.

Offer 5: Higher standards, safer care

1.29 Transforming Care: A National response

to Winterbourne View Hospital7 and the

forthcoming report by Robert Francis

QC into the Mid Staffordshire NHS

foundation trust provide stark reminders

of the consequences for patients if their

needs are not central to everything we

do. All NHS commissioners must work

together with their providers to ensure

the recommendations in those reports

are being addressed. We will include any

relevant recommendations from these

reports within our assurance of clinical

commissioning groups. Specifically,

the Winterbourne View report sets out

responsibilities for clinical commissioning

groups which should lead to a dramatic

reduction in hospital placements for people

with learning disabilities or autism in NHS

funded care who have a mental health

condition or challenging behaviour.

1.30 Compassion in Practice8 sets out a new

approach to improving our culture of

compassionate care and in particular the

actions necessary to maximise the role and

expertise of nurses, midwives and care

staff to deliver improved patient outcomes.

It sets out the necessary values: care,

compassion, competence, communication,

courage and commitment – the 6Cs. As

well as nurses, midwives and care staff, we

expect all staff, including doctors, managers

and support staff to embrace these values.

We all want to see the highest standards of

care, from childbirth where women should

have choice and personalised care through

children’s services and adulthood to the

end of people’s lives.

1.31 Medical revalidation is designed to improve

the quality and safety of care for patients

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by ensuring that licensed doctors are up

to date and fit to practice. Responsible

officers must assure the quality and

appraisal and clinical governance systems

in their organisations to support this

process.

1.32 In partnership with the NHS Leadership

Academy9 we will ensure that the

professionalism of management within the

NHS meets the highest quality standards.

Joined up, local planning

1.33 For the first time, local communities will

drive NHS planning. The new Health

and Wellbeing Boards create a close

partnership between the NHS and

local authorities and bring a new local

accountability to assessing health and

care needs. Both clinical commissioning

groups and the NHS Commissioning

Board Area Teams are members of each

Health and Wellbeing Board. Health

and Wellbeing Boards will be the key

partnership forum for determining local

priorities and providing oversight on their

delivery. At a time of economic challenge

it is vital that all organisations can

understand their contribution to joined up

working. Making the best use of resources

through integration of provision around

the needs of the service user should

drive local priorities. Health and wellbeing

partners have a key role in developing

and supporting reconfiguration to ensure

safe and sustainable services for patients.

We will work with them to identify the

parents of children with special educational

needs or disabilities who could benefit

from a personal budget based on a single

assessment across health, social care and

education.

1.34 Health and Wellbeing Boards are a dynamic

environment where the local health and

wider needs of the population can be

considered in partnership. The Joint

Strategic Needs Assessment and the Joint

Health and Wellbeing Strategy determine

locally what needs to be done to support

better outcomes and a better service to

the public irrespective of organisational

boundaries.

1.35 We have developed a Clinical

Commissioning Group Outcomes Indicator

Set, which includes NHS Outcomes

Framework indicators that can be

measured at clinical commissioning group

level and additional indicators developed

by NICE and the Health and Social Care

Information Centre. These indicators are

published alongside this guidance and will

provide clear, comparative information for

clinical commissioning groups, Health and

Wellbeing Boards, local authorities and

patients and the public about the quality of

health services commissioned by clinical

commissioning groups and the associated

health outcomes. They will be useful for

clinical commissioning groups and Health

and Wellbeing Boards in identifying local

priorities for quality improvement and to

demonstrate progress that local health

systems are making on outcomes. The

Clinical Commissioning Group Outcomes

Indicators have been selected on the basis

that they help contribute to better outcomes

across the five domains of the NHS

Outcomes Framework.

1.36 The NHS Commissioning Board will not

second-guess local priorities because we

want local communities to determine what

matters for them. To make this happen, we

will:

• through clinical commissioning groups,

make available to Health and Wellbeing

Boards all the information we hold that

might support local decision-making;

• provide each clinical commissioning

group and Health and Wellbeing Board

an outcomes support pack which

provides comparative information

at clinical commissioning group and

local authority level; the packs include

benchmarking information relating

to the Clinical Commissioning Group

Outcomes Indicator Set where data are

available; and

• operate on the understanding and

expectation that all data are published,

whether or not the issue it relates to

has been prioritised locally or nationally.

1.37 A robust, joined up approach to planning

would cover each of the following steps:

• ensuring that all local partners are

contributing – local health and care plus

other local authority directors with an

interest;

• understanding how your locality

compares with other areas against

indicators in the outcomes frameworks;

• understanding at a detailed level which

groups of people within the locality are

getting a raw deal from health and care

services;

• engaging in open and creative ways

with local communities to identify what

matters most to them about their health

and care. There is a particular need

to seek out and listen to the voice

and views of currently disadvantaged

groups;

• using this quantitative and qualitative

information to develop shared priorities

based on outcomes that are in greatest

need of improvement and the groups of

people who are most disadvantaged;

• considering explicitly where and

how commissioning budgets can be

integrated whenever this will advance

shared priorities, and taking the

practical steps to ensure that people

who will benefit, including in particular

vulnerable groups and those with long-

term conditions, receive an integrated

experience of care; and

• aligning contracting around the shared

priorities and putting in place mutual

accountability across the partners.

1.38 The NHS Commissioning Board is

committing to being actively engaged in

every Health and Wellbeing Board and will

expect each clinical commissioning group

to be a strong contributor also.

Clinical Commissioning: planning to meet

responsibilities

1.39 As well as being a strong contributor to

the Health and Wellbeing Board process,

each clinical commissioning group will

need to satisfy itself that it is maintaining

its statutory duties to improve the quality of

services, in particular to:

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• reduce inequalities;

• obtain appropriate professional advice;

• ensure public involvement;

• meet financial duties; and

• take account of the local Joint Health

and Wellbeing Strategy.

1.40 For its part, as the oversight body charged

with assessing clinical commissioning

groups against their statutory duties, the

NHS Commissioning Board will provide a

single consistent approach to each of these

areas. What clinical commissioning groups

are asked to do, will be consistent with

how they are held to account, how they are

assessed and how they are rewarded.

Direct commissioning by the NHS

Commissioning Board

1.41 We will directly commission services in five

areas:

• primary medical, dental, pharmacy and

optical services as well as all other

dental services10;

• specialised services11;

• some specific public health screening

and immunisation services;

• services for members of the armed

forces; and

• services for offenders in institutional

settings.

1.42 In doing so, we will aim to use a single

operating model for each of these services

to secure consistency of approach. We will

adopt the same principles that we would

expect clinical commissioning groups and

other partners in the Health and Wellbeing

Board to adopt around the transparency

and publication of information to allow

the public to judge the quality of services

commissioned on their behalf.

1.43 As the national commissioning body, we

will be positioning ourselves as a system

leader and develop exemplar models of

direct commissioning. We will act in a

transparent and collaborative way and be

as challenging on ourselves about quality

improvement and the effective use of

resources, as we are on other parts of the

healthcare system.

1.44 The NHS Commissioning Board is

accountable for ensuring the delivery of

GP IT services and will devolve to clinical

commissioning groups, the responsibility for

operational management of these services.

Clinical commissioning groups should

commission appropriate GP information

services, in line with the published

operating model12. These services will be

expected to provide clinical assurance and

safety, ensuring practices are supplied with

appropriate clinical systems, integration

with national systems and IT support

services.

Emergency preparedness

1.45 There are some areas where national

determination is required. Emergency

preparedness, resilience and response

(EPRR)13 across the NHS remains a core

function of the NHS, required in line with

the Civil Contingencies Act 2004. All NHS

organisations will identify accountable

emergency officers to assume executive

responsibility and leadership at service

13

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and ensure compliance with published

guidance.

1.46 All NHS organisations are required to

maintain preparedness to respond safely

and effectively to a full spectrum of

significant incidents and emergencies that

could impact upon health or patient care,

such as pandemic ‘flu, mass casualty,

potential terrorist incidents, severe

weather, chemical, biological, radiological

and nuclear incidents, and public health

incidents. Trusts must also be resilient

to maintain continuity of key services in

the face of disruption from identified local

risks such as adverse weather, fuel supply

shortages and industrial action.

1.47 From April 2013, all NHS organisations are

required to contribute to the coordinated

planning for both emergency preparedness

and service resilience through their local

health resilience partnerships. These

partnerships will form the basis for all

strategic joint work in this area, with Public

Health England and with all our local

partners. It is important that the NHS

engages proactively at all levels as these

new ways of working will form the basis for

future decision-making.

1.48 Commissioners must ensure that they maintain the current capability and capacity of existing Hazardous Area Response Teams (HARTs) in ambulance trusts.

Protecting patients: continuity of care

1.49 Commissioner Requested Services

are services that will be considered for

protection should a provider fail. Monitor

will publish guidance for commissioners

to follow to ensure that key NHS services

remain available for patients if a provider

experiences serious financial difficulty.

They will form part of Monitor’s Continuity

of Service framework14, which aims to

make sure patients continue to have access

to the services they need in their local area.

1.50 As part of the Continuity of Service

framework, commissioners will decide

which services should be designated

Commissioner Requested Services.

Providers of Commissioner Requested

Services will be subject to additional licence

conditions in the proposed NHS provider

licence.

1.51 Initially, all services offered by NHS

foundation trusts that were previously

identified in their terms of authorisation

as “mandatory services” will automatically

be classified as Commissioner Requested

Services. During 2013/14, commissioners

should begin to review this automatic

classification, in line with Monitor’s

guidance.

Seizing the opportunity

1.52 The NHS belongs to us all. We are

unashamedly ambitious for patients and

will work relentlessly to empower them,

putting them at the heart of the NHS,

ensuring their voices are heard and that

their choices drive the improvements that

will shape our services. We will be realistic

in our ambitions. We will support planning,

providing oversight and assurance, helping

balance immediate and long-term

improvement, and guiding careful use

of resources to ensure current delivery

is not put at risk. In doing so, we need

to be focused on the wider economic

and financial situation, where our push

for improvement will be at a time of

increasing demand for services within

tight financial constraints.

1 https://www.wp.dh.gov.uk/publications/files/2012/11/mandate.pdf2 http://www.dh.gov.uk/health/2012/11/nhs-outcomes-framework/3 http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/ Pages/Overview.aspx4 See Implementing 7 Day working in Imaging Departments : Good Practice Guidance. A Report from the National Imaging Clinical Advisory Group. DH 2011.5 http://www.hqip.org.uk/6 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_134597.pdf7 http://www.dh.gov.uk/health/2012/12/final-winterbourne/8 http://www.commissioningboard.nhs.uk/nursingvision9 http://www.leadershipacademy.nhs.uk/10 http://www.commissioningboard.nhs.uk/files/2012/06/ex-comm-pc.pdf11 http://www.commissioningboard.nhs.uk/files/2012/11/op-model.pdf12 GP IT Services operating model v027 final13 http://www.commissioningboard.nhs.uk/ourwork/gov/eprr/14 http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/our-publications/consultations/consultations-and-engagement-monito-1

15

17

Improving outcomes, reducing inequalities: our responsibilities

2.1 We are committed to improving outcomes

for patients with all mental and physical

conditions that are amenable to health

and care treatment. In supporting clinical

commissioning groups and our own

commissioning to improve outcomes, we

have identified a number of outcome and

delivery measures that commissioners can

use to assure themselves that progress

is being made. These are informed by

our mandate, will help us to deliver it

and will support our accountability to the

Department of Health. The mandate

asks us to oversee improvements against

the NHS Outcomes Framework, ensure

patients’ rights and pledges under the NHS

Constitution are maintained within allocated

resources and with a view to meeting the

QIPP challenge.

Improving outcomes

2.2 Improving the quality of care that patients

receive and the outcomes we achieve for

the people of England is what unites NHS

commissioners in a common purpose.

2.3 The five domains of the NHS Outcomes

Framework help shape what we are striving

to achieve for the patients and populations

we serve:

Preventing people from

dying prematurely

Enhancing quality of life

for people with long-

term conditions

Helping people to

recover from episodes of ill

health or following

injury

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and protecting them from avoidable

harm

Domain 1 Domain 2 Domain 3

Domain 4

Domain 5

Effectiveness

Experience

Safety

Equality and addressing health inequalities

2.4 Within each of these domains, tackling

health inequalities and being focused on

advancing equality will drive everything we

do. Each domain will address inequalities

so that those most in need have most to

gain from the interventions we make. The

outcomes for people with mental health

are as important to us as those for physical

health. Using outcomes in NHS planning

is a radical departure from the pursuance

of process targets. As such, we are at

the beginning of a journey and 2013/14

will be a test-bed year as we develop an

18

understanding of how an outcomes-based

approach will work in practice.

2.5 Throughout this planning round we will

not second-guess local commissioning

by setting improvement requirements but

will expect clinical commissioning groups

and our own commissioners to prioritise

and make most improvement against

those indicators where there is greatest

local need. For each of the five domains,

we have identified the measures from the

NHS Outcomes Framework best placed to

provide assurance in planning and delivery,

where clinical commissioning group data

exists and a baseline can be determined

for 2013/14. These are set out in Annex

A and will be used to inform clinical

commissioning groups and ourselves

on whether progress is being made.

To support local quality improvement

and provide transparency, the Clinical

Commissioning Group Outcomes Indicators

Set published alongside this guidance

will provide additional information for

commissioners and Health and Wellbeing

Boards about the quality of local health

services.

Domain 1: Preventing people from dying prematurely

2.6 The NHS Outcomes Framework has

identified four key contributions to address

premature mortality and the need for better

prevention:

• earlier diagnosis;

• improving early management in

community settings;

• improving acute services and

treatment; and

• preventing recurrence after an acute

event.

2.7 NHS commissioners should work with

Public Health England, Health and

Wellbeing Boards and local government to

develop and provide integrated approaches

to dealing with these issues, for example

through better use of NHS health checks,

so that we can become one of the

most successful countries in Europe at

preventing premature deaths.

Domain 2: Enhancing quality of life for people with

long-term conditions

2.8 We have identified three areas for action

to support the commissioners in providing

person-centred and integrated care for

people with long-term conditions:

• improvements in primary care;

• putting patients in charge and giving

them ownership of their care, such as

through personalised care plans and

budgets; and

• coordination and continuity of care.

2.9 There is a critical role for clinical

commissioning groups and our direct

commissioners to work together under the

auspices of the local Health and Wellbeing

Boards. For example, if each Health and

Wellbeing Board can determine its local

expectation for improved diagnosis of

dementia, we can commission primary

care services in a way that secures

improved diagnosis rates while the clinical

commissioning group can commission

services to reflect the treatment needed.

We can aggregate each of the locally

determined diagnosis rates to identify the

national ambition for 2013/14.

19

Domain 3: Helping people to recover from episodes

of ill-health or following injury

2.10 Avoidable admissions to hospitals need

to be addressed, as well as maximising

the effectiveness of treatment and

providing the right support at the right time.

Commissioners will be expected to support

an approach that:

• keeps people out of hospital when

better care can be delivered in other

settings;

• ensures effective joined-up working

between primary and secondary care;

• delivers high quality and efficient care

for people in hospital; and

• coordinates care and support for

people following discharge from

hospital.

2.11 The NHS Standard Contract will not

allow for hospitals to be reimbursed for

admissions within 30 days of discharge

following an elective admission. Payments

for other readmissions will depend upon

locally agreed thresholds. Commissioners

should work with providers to invest savings

in better reablement and post-discharge

support initiatives.

Domain 4: Ensuring people have a positive

experience of care

2.12 The final arbiter of the outcome of any

NHS interaction is the patient’s experience.

In developing a more patient-centred

approach, we have identified three key

issues that require a commissioner

response during 2013/14:

• rapid comparable feedback on the

experience of patients and carers;

• building a capacity and capability in

both providers and commissioners to

act on patient feedback; and

• assessing the experience of people

who receive care and treatment from

a range of providers in a coordinated

package.

Domain 5: Treating and caring for people in a safe

environment and protecting them from avoidable

harm

2.13 Commissioners should use the National

Quality Dashboard to identify any potential

safety failures in providers. At the same

time, the NHS Commissioning Board is

introducing a zero tolerance approach to

MRSA infections. It will be expected that all

cases will involve a Post Infection Review to

identify why an infection occurred, and how

future cases of infection can be avoided.

For Clostridium difficile, we will support an

approach based on significant reductions

in incidence. Reducing the incidence of

MRSA and Clostridium difficile infections

will be one of the national measures used

to calculate the Quality Premium for clinical

commissioning groups.

Patients rights: the NHS Constitution

2.14 The NHS Constitution sets out the universal

rights and pledges for all NHS patients. We

all aim to ensure the requirements of the

NHS Constitution are met for everyone that

uses NHS services. In doing so we wish

to see mental and physical health valued

equally. Delivery of NHS Constitution

rights and pledges on waiting times for its

patients will be one of the factors taken into

account in determining Quality Premium

payments for clinical commissioning

20

groups. The Department of Health is

consulting on strengthening the NHS

Constitution. For planning purposes, the

NHS Commissioning Board advises clinical

commissioning groups to use the consulted

position which is as set out in Annex B,

together with the thresholds we will use in

assessing organisational delivery.

Eliminating long waiting times

2.15 NHS staff are to be congratulated for the

significant reductions in waiting times

achieved over the past few years. That

success is now documented as patient

rights under the NHS Constitution. Each

patient has a right to access non-urgent

consultant-led treatment within the

maximum waiting time of 18 weeks, or for

the NHS to take all reasonable steps to

offer a range of alternative providers if this

is not possible.

2.16 However, there remains a small number

of patients who are waiting too long. It is

unfair to provide patients with a right and

then not deliver against it. As such, we

wish to identify an absolute minimum for

all patients. From 2013/14 the following

additional safeguard will be in place:

• zero tolerance of any referral to

treatment waits of more than 52 weeks,

with intervention, including contractual

fines when this occurs.

2.17 To ensure treatment takes place as

described in the NHS Constitution, we

will make progress in four areas aimed

at providing patients and commissioners

with the information they need to exercise

choice:

• by April 2013 we will publish examples

of good practice on where patients

have been brought successfully within

the maximum limit waiting times,

including:

i) raising awareness of and

responding to patients’ requests

for treatment at a range of

alternative providers where

treatment within 18 weeks is at

risk; and

ii) use of Patient Tracking Lists

(PTLs) to manage waiting lists

and proactively identify cohorts

of patients who must be treated

to ensure they do not wait longer

than 18 weeks.

• the NHS Standard Contract will make

it a requirement for all letters for first

outpatient appointments to include

standard information on the right to a

treatment within a maximum waiting

time and what patients can do if they

are concerned that they are or will be

waiting longer than 18 weeks;

• we will explore how providers can

inform patients of their estimated

waiting time, as early as possible in

their pathway, including whether they

are at risk of waiting longer than 18

weeks; and

• we will explore how Choose and

Book can be used to raise patients’

awareness of their right to treatment

within 18 weeks and their expected

waiting times and to support them in

choosing alternative providers.

21

More responsive care: urgent and

emergency care

2.18 The response by NHS staff to

emergencies has significantly improved

over recent years so that the NHS

Constitution can provide for minimum

response times for patients in Accident

and Emergency (A&E) Departments or

waiting for an ambulance.

2.19 To help support the integration of services

at the point a patient arrives at an A&E

Department in an ambulance, we are

setting the expectation that:

• all handovers between an ambulance

and A&E Department must take place

within 15 minutes and crews should

be ready to accept new calls within a

further 15 minutes; with

• a contractual fine for all delays over

30 minutes, in both situations, and a

further fine for delays over an hour, in

both situations.

2.20 Neither is it acceptable for patients to be

waiting on trolleys in A&E Departments

and we will expect that as a minimum no

patient experiences a trolley wait of longer

than 12 hours.

Keeping our promises: reducing

cancellations

2.21 The NHS Constitution also includes

a pledge that all patients who have

operations cancelled, on or after the

day of admission (including the day

of surgery), for non-clinical reasons to

be offered another binding date within

28 days, or the patient’s treatment to be

funded at the time and hospital of the

patient’s choosing.

2.22 In support of this, and to improve the

patient experience, we will also expect

that no patient has to tolerate an urgent

operation being cancelled for the second

time.

Mental Health

2.23 We wish to see better outcomes from

mental health services. Our mandate

anticipates the completion of the full roll-out

of the access to psychological therapies

programme by 2014/15 and the NHS

Commissioning Board will expect clinical

commissioning groups to commission

services with that roll-out in mind and for

the recovery rate to reach 50 per cent.

Finance

2.24 We want to promote strong and

autonomous clinical commissioning

groups. In doing so, we want them to

regard their financial resources as the

means to secure better patient outcomes,

rather than numbers to feed into technical

accounting mechanisms. They should

set an annual budget against their plan

and ensure that they operate within it

throughout the year. As such, we will

expect strong clinical commissioning group

financial accountability with greater scrutiny

in those cases where our approach to

risk management has identified that more

regular or in depth financial reporting is

needed. The key measures are:

22

• financial forecast outturn and

performance against plan;

• an assessment of the range of risk

inherent in plans and mitigation

strategies;

• underlying financial position after

adjusting for non-recurrent items;

• triangulation of spend and activity

between commissioning and provider

plans; and

• delivery of running cost targets.

Quality, innovation, productivity and

prevention (QIPP)

2.25 To ensure that the NHS continues to

improve outcomes for patients in years to

come, it is important that we are taking

the significant actions now that will

sustain and safeguard quality in future

years. Focusing just on outcomes in the

coming year, or waiting until later to tackle

foreseeable problems, both fail to live up to

our strategic responsibilities. That is why

QIPP work remains essential. The creation

of clinically-led commissioners comes at a

critical time in delivering improved quality

at a time of limited resource growth. The

first two years of the QIPP challenge have

been dominated by central actions such

as national pay restraint and efficiency

requirements. The health service needs

to be locally driven and undergo radical

transformational change through clinical

service redesign if improvements are going

to support modes of delivery that are both

sustainable and centred on patients’ needs.

From 2013/14, this means a step change

in the approach to QIPP with full local

ownership of the clinical changes needed

to ensure wider service and financial

sustainability.

2.26 The National Quality Board1 has provided

a number of guides that commissioners

can use in meeting their QIPP challenges.

From 2013/14 we will be supporting clinical

commissioning groups in meeting their

own QIPP challenges and will do so in four

ways:

• building on the authorisation process

which provided confidence that each

clinical commissioning group could

articulate its own QIPP challenge and

that it had a solid platform for delivery;

• adopting the “assumed liberty”

approach rather than performance

manage achievement of milestones,

we (through our Area Teams) would

expect to see assurance from each

clinical commissioning group that its

governance processes were robust to

identify and respond to its own QIPP

challenges and milestones over the

next two years;

• ensuring that our direct commissioning

does not sustain outdated or

outmoded service models when

clinical commissioning groups have

identified the need for improved delivery

methods; and

• the triangulation of activity, quality and

cost data and intelligence to provide

overall system assurance.

2.27 As the NHS continues to face the need

to improve efficiency at an increasingly

faster rate, it is essential that as providers

identify ways to secure cost improvements,

23

there is no trade-off with the quality of

services provided. It is the fundamental

responsibility of the Boards of provider

organisations to ensure that any decisions

to reduce costs do not have a negative

impact on the quality of services. To be

contracted to receive NHS services, all

commissioners will operate on the basis

that any cost improvement programmes

must be agreed by the Medical and Nursing

Directors of the provider as having been

assured as clinically safe.

2.28 In addition, the clinical leaders of clinical

commissioning groups must make their

own assessment of cost improvements

and be satisfied that services are safe

for patients with no reduction in quality.

To support decision making they should

use the National Quality Board’s “how

to” guides, the potential impact on local

and nationally accredited tools, such as

the National Quality Dashboard, the NHS

Safety Thermometer and any likely impact

on staff and patient surveys, including the

Friends and Family Test. Before making any

changes to the thresholds for treatment,

clinical commissioning groups must also

be satisfied that their clinical leaders have

confirmed that they are not contravening

NICE guidance.

2.29 To provide assurance on QIPP,

commissioners will want to maintain close

oversight of patient activity and local plans

should include trajectories of how activity

will change over the next two years.

2.30 The NHS Commissioning Board will seek

assurances from the Boards of clinical

commissioning groups that as a minimum

the processes set out above have been

followed so that we can be satisfied that

each decision to change the cost base of

a service has been assessed by clinical

experts and identified as being safe and

without resulting in the rationing of care on

a basis that does not reflect clinical need.

Thus, we will receive systemic oversight

through assurance by:

• eachclinicalcommissioninggroup

providing confirmation that it has

carried out a clinically-led quality impact

assessment of all cost improvement

schemes undertaken by its providers;

• theuseof localmetricsandintelligence

such as the views of staff and patients,

more clinically based tools such as the

NHS Safety Thermometer and other

resources developed locally to reflect

the needs of the local health economy;

and

• alineof sightontheclinical

assurances that there has been no

clinically inappropriate reduction in the

availability of local services.

2.31 Implementation of Innovation Health

and Wealth, accelerating adoption and

diffusion in the NHS remains a priority

for the development of QIPP. All NHS

organisations should demonstrate how

they are driving innovation and developing

delivery mechanisms for long-term success

and sustainability of innovation in their

health economy.

2.32 NHS organisations should demonstrate

their commitment to implementing each

element of the Comply or Explain regime,

1 http://www.dh.gov.uk/health/about-us/public-bodies-2/advisory-bodies/national-quality-board/

and we will set out compliance in the

NHS Standard Contract. Where there is

deviation from compliance then the same

or higher standard must be met. There are

four elements to Comply or Explain:

• automatic inclusion of positive NICE

Technology Appraisals in local

formularies in a planned way that

supports safe and clinically appropriate

practice;

• publication of local formularies;

• tracking of adoption of NICE

Technology Appraisals through the

Innovation Scorecard; and

• support to overcome the system

barriers to implementation of NICE

Technology Appraisal guidance and

other guidelines through the NICE

Implementation Collaborative.

2.33 The first Academic Health Science

Networks (AHSNs) will become

operational from April 2013. All clinical

commissioning groups and our own direct

commissioners should be members of an

AHSN. The AHSNs will present a unique

opportunity to align education, clinical

research, informatics, innovation, training

and education and healthcare delivery.

Their goal is to improve patient and

population health outcomes by translating

research into practice and developing

and implementing integrated health

care services. Working with Academic

Health Science Centres, they will identify

innovations and spread their use at pace

and scale through their networks.

24

25

Tools and levers to support commissioning

3.1 To support commissioners to secure better

patient outcomes, we are providing a

number of financial and related levers that

commissioners can use in their overarching

strategies.

3.2 These levers are structured to support

clinical commissioning groups and the

NHS Commissioning Board’s direct

commissioners to secure quality service

improvements which will deliver better

outcomes for patients, whilst also, in the

first year of reform, maintaining strong

financial management while managing

change.

3.3 Working with stakeholders during 2013/14,

the NHS Commissioning Board will

oversee a fundamental review of the

incentives, rewards and sanctions available

to commissioners to inform the 2014/15

planning round.

Contracting for quality: the NHS Standard

Contract

3.4 The NHS Standard Contract is a key

enabler for commissioners to secure

improvements in the quality of services

for patients. It supports the approach set

out in this guidance and as such will be

the basis on which commissioners should

commission NHS-funded services from

providers. Commissioners must enforce

the standard terms, including the financial

consequences for under-performance or

failure to provide data on which to assess

performance. We will be rigorous in

supporting clinical commissioning groups

and our direct commissioners to ensure the

contract terms are implemented.

3.5 The NHS Standard Contract will be revised

for 2013/14 to support commissioners

to hold providers of NHS funded care

to account and to enable innovative

commissioning. The final version of

the NHS Standard Contract will be an

“e-Contract” format, which will enable

contracts to be tailored to the specific

services commissioned. We will make a

wide range of supportive guidance, tools

and learning available to commissioners.

Rewarding quality through provision:

commissioning for quality and

innovation (CQUIN)

3.6 CQUIN presents an opportunity for

commissioners to secure local quality

improvements over and above the norm by

agreeing priorities with their providers. It is

set at a level of 2.5 per cent of the value of

all services commissioned through the NHS

Standard Contract.

3.7 CQUIN should only be paid by

commissioners when providers deliver a

level of quality that is over and above the

NHS Standard Contract. The 2.5 per cent

amount will provide local commissioners

with significant freedom to negotiate greater

and locally-focused quality from providers.

Within the total, one-fifth should be linked

to the national CQUIN goals, where these

apply, which for 2013/14 will be:

• Friends and Family Test – where

commissioners will be empowered to

incentivise high performing Trusts;

• improvementagainstthe NHS Safety

Thermometer - (excluding VTE),

particularly pressure sores;

• improving dementia care, including

sustained improvement in Finding

people with dementia, Assessing

and Investigating their symptoms and

Referring for support (FAIR); and

• Venous thromboembolism - 95 per

cent of patients being risk assessed

and achievement of a locally agreed

goal for the number of VTE admissions

that are reviewed through root cause

analysis.

3.8 We will provide guidance to commissioners

on the methodology to be used to measure

performance against each of these

indicators.

3.9 CQUIN payments will only be made to

those providers that meet the minimum

requirements of the high impact innovations

as set out in Innovation, Health and Wealth.

These minimum requirements, including

how clinical commissioning groups can

identify whether they have been met will

be in guidance published by the NHS

Commissioning Board.

Rewarding quality through commissioning:

quality premium

3.10 Subject to Regulations, a Quality

Premium will be paid in 2014/15 to clinical

commissioning groups that in 2013/14

improve or achieve high standards of

quality in the following four measures from

the NHS Outcomes Framework (which are

also included within the measures at Annex

A):

• potentialyearsof lifelostfromcauses

considered amenable to healthcare;

• avoidableemergencyadmissions

(a composite of four NHS Outcome

Framework indicators);

• theFriendsandFamilyTest;and

• incidenceof healthcareassociated

infections (MRSA and Clostridium

difficile).

3.11 The Quality Premium will also include three

locally identified measures. Each clinical

commissioning group should agree these

measures with the NHS Commissioning

26

Board after consideration with Health and

Wellbeing Boards and key stakeholders,

especially patients and local community

representatives.

3.12 These measures should focus on local

issues and priorities, especially where the

outcomes are poor compared to others

and where improvement in these areas will

contribute to reducing health inequalities.

3.13 Each measure should be based on robust

data and the improvement needed to

trigger the reward should be expressly

agreed between the clinical commissioning

group and our Area Team. Where there

is concern about the validity of data,

the measures identified in the Clinical

Commissioning Group Outcome Indicator

Set should be used as a default.

3.14 A significant quality failure in-year

will automatically debar a clinical

commissioning group from receiving a

Quality Premium. A clinical commissioning

group will not receive any Quality Premium

reward if it has overspent its approved

Resource Limit in 2013/14. Payment of the

Quality Premium will also be dependent

upon achieving NHS Constitution rights and

pledges.

3.15 We will publish the methodology to be used

for calculation of the Quality Premium.

Financial planning and business rules

3.16 The income allocated to clinical

commissioning groups has been published

alongside this guidance.

3.17 Templates for the collection of key financial

data for both clinical commissioning

groups and our direct commissioners have

been issued. The templates have been

constructed to enable an assessment of the

risk inherent in plans and triangulation of

plans with providers. Detailed instructions

for completion are included with the

templates.

Programme and running costs

3.18 Income is allocated separately for

programme and administrative costs.

Expenditure against these allocations will

be tracked individually. Commissioners

are asked to ensure that plans are in place

to ensure administrative costs are not

overspent. Underspends on administrative

costs may be spent on programme costs.

Clinical commissioning groups should plan

property costs based upon pro rata share

of Primary Care Trust costs collected

through the 2012/13 baseline exercise.

The total amounts will be communicated to

clinical commissioning groups separately.

Surplus policy

3.19 Each commissioning organisation should

plan to make a cumulative surplus at the

end of 2013/14 of at least 1 per cent of

revenue, including any historic surplus not

drawn down. This will be carried forward

into 2014/15.

3.20 Ownership of historical surpluses

and deficits at 31 March 2013 will

see Primary Care Trust accumulated

surpluses up to the level of the 2012/13

27

28

operating plans attributed to individual

clinical commissioning groups and direct

commissioning units in proportion to the

final 2012/13 baselines. Strategic Health

Authority surpluses will be managed at

a national level. Any 2012/13 deficits

will also be the responsibility of relevant

clinical commissioning groups and direct

commissioners.

3.21 The maximum expected level of the

national surplus drawdown will be finalised

with the Department of Health. Any

surplus drawdown will be deployed across

three areas:

• clinicalcommissioninggroupallocated

share of drawdown;

• ourdirectcommissioning;and

• systemrequirementsincluding

existing Strategic Health Authority

commitments.

3.22 Commissioners are asked to include

proposals for access to historical surpluses,

if required, in their operating plans. The

plans will be assessed with reference to

the impact on outcomes and subject to the

maximum drawdown available. Drawdown

agreements will be finalised by the end of

April 2013.

3.23 A key measure of financial resilience

of an organisation is the recurrent, or

underlying, financial position after stripping

out non-recurrent income and expenditure.

Commissioners should plan to be in 2

per cent recurrent surplus by the end of

2013/14. We will publish guidance on

how this requirement will be defined and

measured by the end of January 2013.

Managing risk

3.24 It is important to ensure that our approach

to risk management provides flexibility

whilst providing sufficient mitigations

against financial risks. These include:

• riskpoolingbetweenclinical

commissioning groups;

• policyfor2percentof incometobeset

aside and spent non-recurrently; and

• contingencies.

3.25 In 2013/14, there is a requirement across all

commissioning organisations to set aside

2 per cent of funding for non-recurrent

expenditure. Clinical commissioning groups

are expected to ringfence these funds and

make expenditure commitments against all

or part of them only following appropriate

approval via NHS Commissioning

Board Area Teams. Our own direct

commissioners will also ringfence the

funds, and release all or part only following

approval via the national support centre.

3.26 Clinical commissioning groups must

demonstrate that appropriate risk

management and pooling arrangements

are in place internally and between clinical

commissioning groups to ensure budgets

are achieved. NHS Commissioning Board

Area Teams will ensure that effective risk

management and pooling across directly

commissioned activity are in place to

mitigate risk.

3.27 Clinical commissioning groups are asked to

hold a contingency of at least 0.5 per cent

of revenue within their plans to determine

locally the contingency required to mitigate

29

risks within the local health economy. This

is in addition to 2 per cent ringfenced

non-recurrent funds. Our own direct

commissioners will also hold a minimum

0.5 per cent contingency.

Planning Assumptions

3.28 Clinical commissioning groups and NHS

Commissioning Board direct commissioning

units should plan for an underlying growth

in demand based upon both demographic

and non-demographic changes.

3.29 The running cost allowance for clinical

commissioning groups in 2013/14 has

already been identified to individual clinical

commissioning groups in line with the total

overall national allocation of £25 per head

of population.

3.30 The national provider efficiency requirement

for 2013/14 tariff setting is 4 per cent. This

will be offset against estimated provider

cost inflation of 2.7 percent. This gives

a net tariff adjustment of -1.3 per cent,

which will also be the base assumption for

discussions on price for services outside

the scope of the mandatory tariff.

3.31 The 30 per cent marginal tariff for

non-elective admissions will continue.

Commissioners should budget for all

admissions at 100 per cent tariff. NHS

Commissioning Board Area Teams will

administer the 70 per cent balance for

local investment in relevant demand

management schemes, jointly owned by

commissioners and providers. Decisions

on how to spend this resource will be

undertaken by NHS Commissioning Board

Area teams in partnership with clinical

commissioning groups.

Integrated care

3.32 The integration of the provision of

services, including the pooling of budgets

to reflect local need, should be an explicit

consideration in local area planning.

3.33 Clinical commissioning groups will

assume responsibility for the management

and administration of the £300 million

a year reablement provision. Clinical

commissioning groups will work with

local authorities to agree allocation of

the monies to benefit health outcomes in

their local population. They will account to

their Health and Wellbeing Board and the

Area Team on how health and care have

benefited from the allocation.

31

4.1 We will support clinical commissioning

groups to ensure that every plan is as

strong as it can be. The approach set out

in this guidance aims to strike a balance

between local determination of priorities

and our responsibility for oversight to

ensure that statutory requirements around

improving quality and financial duties are

being met.

4.2 We are not setting any specific targets for

improvement of those indicators contained

within the NHS Outcomes Framework

other than a defined level of continued

reduction in Clostridium difficile infections.

Rather than imposing targets, we expect

clinical commissioning groups to develop

their own local priorities through their

input into the Joint Health and Wellbeing

Strategy. However, with assumed liberty

comes public responsibility and clinical

commissioning groups are expected to set

out real ambition in their plans. We will

provide support and challenge where we

have evidence to suggest greater ambition

is needed. In addition to the measures

referred to in Section 2 of this guidance,

and to support local prioritisation, the

PLANNING AND ASSURANCE

NHS Commissioning Board is asking each

clinical commissioning group to identify

three local priorities against which it

needs to make progress during the year.

These priorities will also form part of our

assurance of each clinical commissioning

group and will be taken into account when

determining if the clinical commissioning

group should be rewarded through the

Quality Premium.

4.3 Our planning and assurance approach

reflects the three lenses set out in Section 1

of this guidance, namely:

• Localareabasedplanning: each

Health and Wellbeing Board is

expected to determine and oversee

delivery of local priorities. Both

clinical commissioning groups and the

NHS Commissioning Board itself are

members of each Health and Wellbeing

Board and as such will be strong

contributors to and be held to account

against, the priorities determined by the

Health and Wellbeing Board.

• Clinicalcommissioninggroup

organisationalplanning: we will

expect each clinical commissioning

group to monitor progress against each

of the measures referred to in Section

2 of this guidance. That will involve

reporting to the clinical commissioning

group’s governing body and to the

NHS Commissioning Board’s Area

Team so that they can both monitor

progress. Each clinical commissioning

group should also agree with our Area

Team, three priorities it has identified

for improvement and against which

progress can be monitored. These

three priorities should be the same that

will be used to determine the Quality

Premium. Clinical commissioning

groups are expected to improve

outcomes across the full range of the

NHS Outcomes Framework and act

proactively, with our support when

appropriate, should they identify or

anticipate a quality or safety issue in a

provider. That includes wider system

responses, such as acting on the

Winterbourne View and Francis reports.

• DirectcommissioningbytheNHS

CommissioningBoard: we have

set ourselves the goal of being a

demonstrable exemplar commissioner.

In doing so we will publish assessments

of our own performance across the

range of our direct commissioning

responsibilities and be transparent

about any failings and our response

to them. We will expect our direct

commissioners to account to clinical

commissioning groups on our

performance so that we can work

together to deliver joined up care for

patients.

Planning timetable

4.4 We will review the local improvement

identified by clinical commissioning groups

against the measures referred to in Section

2 of this guidance so that we can be

satisfied that we are fulfilling our statutory

duties to (i) deliver the mandate and (ii) be

satisfied that clinical commissioning groups

are making sufficient contribution to quality

improvement within allocated resources.

4.5 We will be taking an “open book” approach

where we expect clinical commissioning

groups and NHS Commissioning Board

Area Teams to share data and planning

assumptions on a transparent basis so that

both can be satisfied that their plans secure

the best possible outcomes for patients

within available resources.

4.6 We will build on the authorisation process

which required clinical commissioning

groups to develop clear and credible plans

and as such will already have a strong base

on which to develop 2013/14 plans. NHS

commissioners should develop plans on the

basis of the following timetable:

32

4.7 High quality planning is needed to deliver

effective improvements for patients. All

clinical commissioning groups should use

the best available expertise to support

them, whether through Commissioning

Support Units or secured through other

means.

Clinical commissioning group assurance

4.8 We will use the measures in Section 2

of this guidance to provide assurance

that clinical commissioning groups and

33

Date Activity

CCG Plans Direct Commissioning Plans

w/c 17 Dec 12 Allocations publishedPlanning guidance published

Draft supporting information publishedDraft NHS Standard Contract published

25 Jan 13 CCGs to share first draft of plans with Area Team Directors to include:

• “PlanonaPage”including(i) key elements of transformational

change; (ii) key risks; and(iii) confirmation that national

requirements will be met;• trajectoriesonrelevantmeasuresin

Section 2 plus three local priorities;• activityplans–summaryat

commissioner level;• financialinformation

Area Team Directors to share first draft of plans with Regional Directors to include:

• “PlanonaPage”foreachelementof their direct commissioning; including confirmation that national requirements will be met;

• keyrisks;• activityplans;• trajectoriesonrelevantmeasures;• financialinformation

By 8 Feb 13 Area Directors to provide feedback to CCGs Regional Directors to provide feedback to Area Team Directors

11 Feb to29 Mar 13

Discussions to support Area Team Director assurance of plans

Regional and Area Team Director discussions to support assurance of plans

31 Mar 13 CCG and NHS Commissioning Board contracts signed off

5 Apr 13 Final CCG plans shared with Area Team Director

Final direct commissioning plans shared with Regional Director

8 Apr to 19 Apr 13

Board analyses CCG plans and plans for direct commissioning with a view to identifying risks to delivery

22 Apr to 10 May 13

Board confirms that plans add up to a position that delivers the mandate and improves patient outcomes within allocated resources

By 31 May 2013 Each clinical commissioning group publishes its prospectus for its local population

the NHS Commissioning Board’s direct

commissioners are fulfilling statutory duties.

This will include:

• ensuringthatclinicalcommissioning

groups have taken the appropriate

action to allow for authorisation

conditions to be lifted at the earliest

opportunity;

• anapproachtoreportingthatensures

that the measures referred to in Section

2 are tracked effectively; and

34

• interventionwhereclinical

commissioning groups are not fulfilling

their statutory duties.

Clinical commissioning group annual

assessment

4.9 We have a statutory duty to carry out

an annual assessment of each clinical

commissioning group and we will build

this into our approach to assurance.

Our annual assessment of a clinical

commissioning group will be based on it, in

particular:

• improvingthequalityof services;

• reducinginequalities;

• obtainingappropriateprofessional

advice;

• publicinvolvement;

• meetingfinancialduties;and

• takingaccountof thelocalJointHealth

& Wellbeing Strategies.

4.10 We will set out the basis on which we will

carry out our annual assessment of clinical

commissioning groups in 2013/14 by 31

March 2013. In doing so, we will ensure that

the assessment is based on meeting the

expectations set out in this guidance and

meeting wider statutory duties including

seeking the views of partners within the

local Health and Wellbeing Board. The

approach will build on that used in clinical

commissioning group authorisation. Annual

assessment will build on the six domains

of authorisation, with elements updated

to take account of learning from the

authorisation process. Relevant aspects

of the assessment as detailed within the

Quality Premium will be taken into account

before determination of the payment of any

Quality Premium.

35

Annex A

NHS Outcomes Framework measures which the NHS Commissioning Board and Clinical Commissioning Groups will use to track progress (ie data can be generated at Clinical Commissioning Group level and a baseline can be determined against which progress can be considered).

1. Preventingpeoplefromdyingprematurely

Potential years of life lost (PYLL) from causes considered amendable to healthcare

Under 75 mortality rate from cardiovascular disease

Under 75 mortality rate from respiratory disease

Under 75 mortality rate from liver disease

Under 75 mortality rate from cancer

2. Enhancingqualityoflifeforpeoplewithlongtermconditions

Health-related quality of life for people with long-term conditions

Proportion of people feeling supported to manage their condition

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)1

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s1

Estimated diagnosis rate for people with dementia

3. Helpingpeopletorecoverfromepisodesofillhealthorfollowinginjury

Emergency admissions for acute conditions that should not usually require hospital admission1

Emergency readmissions within 30 days of discharge from hospital

Total health gain assessed by patients i) Hip replacement ii) Knee replacement iii) Groin hernia iv) Varicose veins

Emergency admissions for children with Lower Respiratory Tract Infections (LRTI)1

4. Ensuringthatpeoplehaveapositiveexperienceofcare

Patient experience of primary care i) GP Services ii) GP Out of Hours services

Patient experience of hospital care

Friends and family test

5. Treatingandcaringforpeopleinasafeenvironmentandprotectingthemfromavoidableharm

Incidence of healthcare associated infection (HCAI) i) MRSA ii) C.difficile

1Will be used as part of a composite measure on emergency admissions

36

Annex B

Expected rights and pledges from the NHS Constitution 2013/14 (subject to current consultation) including

the thresholds the NHS Commissioning Board will take when assessing organisational delivery.

ReferralToTreatmentwaitingtimesfornon-urgentconsultant-ledtreatment

Admitted patients to start treatment within a maximum of 18 weeks from referral – 90%

Non-admitted patients to start treatment within a maximum of 18 weeks from referral – 95%

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral – 92%

Diagnostictestwaitingtimes

Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral – 99%

A&Ewaits

Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department – 95%

Cancerwaits–2weekwait

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP – 93%

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) – 93%

Cancerwaits–31days

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers – 96%

Maximum 31-day wait for subsequent treatment where that treatment is surgery – 94%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen – 98%

Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy – 94%

Cancerwaits–62days

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer – 85%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers – 90%

Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) – no operational standard set

CategoryAambulancecalls

Category A calls resulting in an emergency response arriving within 8 minutes – 75% (standard to be met for both Red 1 and Red 2 calls separately)

Category A calls resulting in an ambulance arriving at the scene within 19 minutes – 95%

MixedSexAccommodationBreaches

Minimise breaches

CancelledOperations

All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice.

Mentalhealth

Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period – 95%.